KCAP SITE
NEAR MISS / INCIDENT
REPORT
Near Miss – Events that under slightly different
circumstances could have resulted in injuries to
persons or damage to equipment, property or to
the environment
Incident – an event that did not result in a safety
issue where property was damaged and / or
site/company rules were violated.
Date and Time of Incident
Date:
Time:
Type of Report
[
] Near Miss
Persons(s) Involved:
Department:
[ ] Incident
Supervisor:
Person Completing Form:
Department:
Supervisor:
Witness(es):
Department:
Supervisor:
Location: (If outside building, give reference to nearest building)
Description (Describe in your own words what happened)
Corrective Actions (What do you think should be done to prevent a recurrence?
Only required for Near Miss)
Response (What actions were taken since the near miss/incident)
Responder Name:
Reporting Procedure
1. Fill out the form anytime you identify an issue.
2. Give a copy of this form to your supervisor or submit to Omni office.
3. If you have given your name or your supervisor’s name, responses will be provided within three
days of reporting the near miss.
F416-0001/Rev.No:1/06/07